HomeMy WebLinkAboutPATNODE BLK 1 LT 3
*'~' ~ ,' ,~,~,'~' MUNICIPALITY OF ANCHORAGE
'.,~ ' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME [PHONE hE
MAI LING ADDRESS
LEGAL DESCRIPTION ~
LOCATION NO. OF BEDROOMS
]Well AbsorPtion Dwelling ~ PERMIT NO,
~ ~ Manufacturer ~ ~'~ Material~~ N°' of compartments
Liq, capacity in gallons Inside I~ngth Width Liquid depth
~ -- ~ Manufacturer Material Liquid capacity in gallons
No, of lines Distance between lines
~ Top of tile to finish grade ~ ] Material beneath tile Total
~ Length Width ,~j / Depth PERMITNO,
~ Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
~Class
I i Dr,,,er D,stanceto,ot,ine PERM,TNO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
REMARKS
~P~V~/// ~ (l DATE LEGAL
13 (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE
Department ~ Health and Environmenta? ~rotection
825~ Street,264-4720 Anchorage, AK. ~9501 ~~ ~~,
* * * HANDWRITTEN PERMIT * * *
Permit
~,.~-~-~ '' WELL AND/~ON-SITE SEWER PERMIT
APplicant: ~T~/ ,A,/.~.~ Mailing Address: ,,~..~
LOcation: . . Phone Number: ~9,.~ 13~ 7
L~gal Description: L ~ ~,~]2)/~7'""/%/~ -~//--~, Lot Size:
Type of Soil Absorption System Is:
Trench: ~ Drainfield: Seepage Bed: Holding Tank: ...
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
DEPTH 7! LENGTH ~'.~"' GRAVEL DEPTH ~/L!
... WIDTH
The length dimension is the length(in feet) of. the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground an:d
the .bottom of the excavation(in feet). There is. no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(+tg'L-D-I-NS) TANK SIZE = /~,,~'CD GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of. residences that the well will serve. --
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
i.s 25 feet"and to a community sewer line is 75 feet.- Well logs are required
and must be returned-to this department within 30 days- of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31~ 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more tha~
Applicant .....
Date:
SWP/024 (1/81)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
20
COMMENTS
MUNICIPALITY OF ANCHORAGE
DEPARTIVlENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
.~~.. _~ ' DATE PERFORMED:
IF YES, AT WHAT
DEPTH?
Robert A.
No. 1~7-E
SLOPE
O
P
E
SOl LS LOG
[] PERCOLATION
TEST
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
72-008 (6/79)
FT AND
(minutes/inch)
~ FT
o
(.9
0 0 0 0 0 0 0 0 0 0 0 0
rD 0 0 U
0 0 0 0
0
0
['--! o tn! ~ ~:: ~ o
co! t'-- o! ~ co~ c'q ~
~i o t'--', co o o
0 0 0 0 0 0 0 0
o
o
o
''
0
r.~
.<
z
MUNICIPALITY OF ANCHORAGE ~i~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
1. GENERAL INFORMATION
Complete legal des~:ription
CERTIFICATE OF HEALTH AU'FHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
.r'~C~ - ~'~ ~ - ~ HAA#
Lot 3; Bloc~.';1? 'Pat~ode Sabdivision
Location (site address or directions)
18811Jamie Drive
Property owner
Mailing address
~,,,, ~~ 338-7768
· ~,,e'"~ ~,,:,d .~,r.,~ t_.~, Day phone
C/O Coldwell Banker 4105 T~dor Centre Drive Anchorage, AK
Lending agency
Mailing address
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
NOTE:
4 ~
XXX
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
995085
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my inves_ti_gation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date ~s inspection.
Name of Firm
17034 Eagle Ri~er ~,~.p RO~ld/N®,
Address Eagle River~~~-
Engineer's signature
.~',
DHHS SIGNATURE
X' Approved for
Phone
Date
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: ,/~'-~-~ ~ Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025(Rev. 1/91) Back MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~,-d~-~ ~;Z2~v.~\ ?~>Dr~ '[o Parcel I.D.
A. Well Data
Well type ~¢. ~,q ~
Log present ~) -(
Total depth \ ,~ o'
Sanitary seal ~N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed '~ ~ ~ ~% ~ Driller
Cased to ,~-o ~ Casing height
Wires properly protected ~N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
AT INSPECTION
g.p.m. ~ ,/-J" g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
m
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Date of sample:
Nitrate
B. SEPTIC/HOLDING TANK DATA
Date installed '7 ~ ~/'(~'~ :~
-- Tank size
Collected by:
Other bacteria ~
$ & $ ENGINEERING
; 7G$4 F. as;e ~,;wr L~p ~,ga& No. ~.~-~4
Eagle River, Alaska 99577
Compartments
Cleanouts ~YN) '~
High water alarm (Y~.
Date of pumping
Dep ressio, n~Y~)
Alarm tested (Y/N) ~ L,~'
Foundation cleanout ~/N)
PUmper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot J o o On adjacent lots / 0 o
To property line \ ~ ~ '~ ~ ~
Surface water/drainage
Foundation
Absorption field
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Manufacturer
"Pump on" level at
Meets MOA electrical codes (Y/~.-----'"~
S~ROM LIFT STATION
TO:
Well on lot On adjacent lots
Manhole/Access (Y/N)
sted
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ -- ~'~
Length 5'"" 5" /
Total absorption area
Date of adequacy test
Width
Water level in absorption field before test
Soil rating (GPD/Ft2)
~ (-,- '~ Gravel thickness
Cleanout present~/N)
Results~l'ail)
Peroxide treatment (past 12 months) (Y~ ~.~ ,,~.~.. V~,~ ~[ ~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
System type
Total depth / o
y Depression over field (Y~I~
f'"',,4-5_5 for Z/L
After test ~
If yes, give date ~,~
Bedrooms
Well on lot ~ c~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots
~ o ~ Property line
To existing or abandoned system on lot
Cutbank /J~ Water main/service line
Driveway, parking/vehicle storage area '~'"-'~)
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, orconform_j~ all MOA andH, rAA gu/deline~p~_e)' . . ~( ~,.~_~fa.~b~..~,~/~, .w.~.~ ~ . inspection
En ineer's N 034 Eagle Ri
Date E~leRiv~, A
HAA Fee $ r~ ~)E::' , ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Zt vCOMMERClAL TESTING &
IRONMENTAL LABORATORY SERVICES
ENGINEERING CO.
SINCE 1908
Chemlab Ref. ii : 93
c... ~ ~ PATNODE:
(]lJ. erlt ~,am,..l~ID :1...3 BI
~lYj't: r :t x : WATER
il r' e
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 562-2343
FAX: (907) 561-5301
Client Name :S & S ENGIHEERING NOR[{ Order :'t0272
O:c'dered By ~RAY SHAFE:R Report Compl.eted :09/02/93
Pr'oject Name : Col.!ected : 08/30/93
P~oject~ ;: Received :08/30/93
PWS1D :I]A Tecnnzcal, Dzr ~.c'tor
OC Allowable Ext ,.
Par-ameter Re'_~;2ua ].~- U~,it-s Mett-,od, gimi'ts 13at~
t'it'tra'te-N /2.49] mg/[., EPA ::,:-,3.2/a00.0 10 U9/01 f LH
Il :: llnd~et:ec'tt:~d., Repo:i't. ed v~]ue i~; tile p;t'a(:tJ.(~a]. ,:_'.uaF~tJ. lfic;:d:ion iiilh~!:~ [,7' :n I?~SS
Member of the SGS Group (Soci(~,~ G~n(~rale de Surveillance)
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
· CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
(c) Lending Institution
Mailing Address
Location (address or directions)
..?~..r.opertyowner '~") ,~%J, ~( Telephone'(horne) ~?~/-~L~")Business
~... MaitingAddress /~/~~J~ ~
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here [], if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family,S,, Number of bedrooms
3. WATER SUPPLY
Individual Well ~1~
Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site'~,,~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
Name of Firm
Address
Date
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION .
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional .and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
~~ ~ ~ Telephone
Engineer's Seal
6. DHHS APPROVAL
Approved for /=b~c ~edrooms by
Approved /~ Disapproved
Terms of Conditional Approval
Conditional
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
.~;~:?~IUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (NAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description:
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Date Completed
If A, B, C, D.E.C. Approved (Y/N)
Yield ~ 3/~ ~
Total Depth /~O Cased to //'O Depth of Grouting
Static Water Level ~ .5, Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) ,ky/
/
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot /
tarest Edge of Absorption Field on Lot
Pu;licS~ewer Line /'~_ _
-TO ~'Sewer ServiCe Line on Lot
Sanitary Seal on Casing (Y/N) /v'
Depression Around Wellhead (Y/N)
'/~ ;On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
'PATH
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
........ / ~
Date Installed ~/~.5'~9,~ Size
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Air-tight Caps (Y/N) ~
No. of Compartments 7-pC, o
Foundation Cleanout (Y/N)
Date Last Pumped ['-{ ~.¢.,
;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line
J ~o ¢ To Building Foundation /,~ ¢
To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field ./
Gravel Bed Thickness
/"//-/'~;~ Statndpipes Present (Y/N)
Date of Last Adequac. v Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Jg~:~ To Property Line ~ / O
To Existing or Abandoned System on
; On Adjoining Lots ~;~/C)
-.~ /(~ TO ~ (if present) ~
f'
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, o.,r conformed to all MOA and HAA guidelinesin effect on the date of this
inspecti°n' 'X~'~' ~j,,~ ~,,, ,//" ..~7;~ (.~ ~:~.~?~ ~"
uompany , ' , tr . ' --
, , .-., ,' x~'::,:. Engineer's Seal
Date ~/~[~' ; ~~.~,~
MOA No.
Rece pt.o.
Amount: $ //,./~ ~
72-026 (Rev, 7~88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
APPLIC NT FILLS OUT UPPER HAl.. ONLY
Phone
Buyer
Realty Co. & Agent (~ Phone
Address ,A,~/~/;~¥_ Zip Code
Legal
Description
/ ~,~ ·
Type of Residence
Single Family
No. of Bedrooms
Multiple
Family
[] Other
Water Supply
,lndividual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
Community/~'',,~ ~! For wells drilled prior to that date, give well depth (attach log if available).
[] Public Utility 0
Sewer Disposal
Year Individual Installed: /
Individual
Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes: L~,.~..~- . MUNICIPALITY OF ANCHO~GE
.h
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL* ~
DATE I ~7-- ~-~ ~
"7 ~ ~> '-
Well to Tank 5~ 5' ~'Se~ Size
72-023 (3/82)
,3ohn P. Nix, Jr.
P. O. L~ox 772513
Eagle 3Xiver, ~.%1.~ 995"/7
,'-3ubject: Lot 3, ~'atnod~} Subdivision, ~.!:agle .Riw}r
Approval for thc individual se,,~ur and '~;ater facilities cannot
be gra~lted ,~rltil the following items [lave b~}~,.fl cotni~i~ted:
A ~,ell log submitted to this office Jor O~]E fil(;s and
review.
Ple~se notify this Department for a rei~]:~[2ec~ion wi'~en t,he
noted discre}sancies have been corrected. If there, are any
further <.]uestions, ]{)lease call this office at 264-~720.
S i,uce r ely,
Cory Willis, I%.S.
Act inq" .... r
.. oewe & ~'~ater
Program ~anager